CANCER OF THE LUNG (BRONCHOGENIC CANCER)

Bronchogenic cancer refers to a malignant tumor of the lung arising within the wall or
epithelial lining of the bronchus. The lung is also a common site of metastasis by way of
venous circulation or lymphatic spread. Bronchogenic cancer is classified according to
cell type:

• Epidermoid (squamous cell) most common

• Adenocarcinoma
• Small cell (oat cell) carcinoma
• Large cell (undifferentiated) carcinoma

PATHOPHYSIOLOGY AND ETIOLOGY

Predisposing Factors

1. Cigarette smoking amount, frequency, and duration of smoking have positive

relationship to cancer of the lung.
2. Occupational exposure to asbestos, arsenic, chromium, nickel, iron, radioactive
substances, isopropyl oil, coal tar products, petroleum oil mists alone or in
combination with tobacco smoke.

Staging

1. Refers to anatomic extent of tumor, lymph node involvement, and metastatic

spread.
2. Staging done by:
a. Tissue diagnosis
b. Lymph node biopsy
c. Mediastinoscopy

NURSING ALERT
Suspect lung cancer in patients who belong to a susceptible, high-risk group and who
have repeated unresolved respiratory infections.

Clinical Manifestations
Usually occur late and are related to size and location of tumor, extent of spread, and
involvement of other structures

1. Cough, especially a new type or changing cough, results from bronchial irritation.
2. Dyspnea, wheezing (suggests partial bronchial obstruction).
3. Chest pain (poorly localized and aching)
4. Excessive sputum production, repeated upper respiratory infections
5. Hemoptysis
 6. Malaise, fever, weight loss, fatigue, anorexia
7. Paraneoplastic syndrome metabolic or neurologic disturbances related to the
secretion of substances by the neoplasm
8. Symptoms of metastasis bone pain; abdominal discomfort, nausea and vomiting
from liver involvement; pancytopenia from bone marrow involvement; headache
from CNS metastasis
9. Usual sites of metastasis lymph nodes, bones, liver

DIAGNOSTIC EVALUATION

1. Computed tomography (CT) scan and positron-emission tomography (PET) scan

are indicated because lung cancers may be partly or completely hidden by other
structures on chest X-ray.
2. Cytologic examination of sputum/chest fluids for malignant cells.
3. Fiber-optic bronchoscopy for observation of location and extent of tumor; for
biopsy.
4. PET scan sensitive in detecting small nodules and metastatic lesions.
5. Lymph node biopsy; mediastinoscopy to establish lymphatic spread; to plan
treatment.
6. Pulmonary function tests (PFTs) combined with split-function perfusion scan to
determine if patient will have adequate pulmonary reserve to withstand surgical
procedure.

MANAGEMENT

1. The treatment depends on the cell type, stage of disease, and the physiologic status
of the patient. It includes a multidisciplinary approach that may be used separately
or in combination, including:
a. Surgical resection.
b. Radiation therapy.
c. Chemotherapy.
d. Immunotherapy.

COMPLICATIONS

1. Superior vena cava syndrome oncologic complication caused by obstruction of

major blood vessels draining the head, neck, and upper torso.
2. Hypercalcemia commonly from bone metastasis.
3. Syndrome of inappropriate antidiuretic hormone with hyponatremia and abnormal
water retention
4. Pleural effusion
5. Infectious complications, especially upper respiratory infections
6. Brain metastasis, spinal cord compression, pulmonary scarring
NURSING ASSESSMENT

1. Determine onset and duration of coughing, sputum production, and the degree of
dyspnea. Auscultate for breath sounds. Observe symmetry of chest during
respirations.
2. Take anthropometric measurements: weigh patient, review laboratory biochemical
tests, and conduct appraisal of 24-hour food intake.
3. Ask about pain, including location, intensity, and factors influencing pain.

NURSING DIAGNOSES

1. Ineffective Breathing Pattern related to obstructive and restrictive respiratory

processes associated with lung cancer
2. Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolic
state, taste aversion, anorexia secondary to radiotherapy/chemotherapy
3. Acute or Chronic Pain related to tumor effects, invasion of adjacent structures,
toxicities associated with radiotherapy/chemotherapy
4. Anxiety related to uncertain outcome and fear of recurrence

NURSING INTERVENTIONS

1. Prepare patient physically, emotionally, and intellectually for prescribed therapeutic

program.
2. Elevate head of bed to promote gravity drainage and prevent fluid collection in
upper body (from superior vena cava syndrome).
3. Teach breathing retraining exercises to increase diaphragmatic excursion with
resultant reduction in work of breathing.
4. Give prescribed treatment for productive cough (expectorant, antimicrobial agent)
to prevent thickened or retained secretions and subsequent dyspnea.
5. Augment the patient's ability to cough effectively.
a. Splint chest manually with hands.
b. Instruct patient to inspire fully and cough two to three times in one breath.
c. Provide humidifier/vaporizer to provide moisture to loosen secretions.
6. Support patient undergoing removal of pleural fluid (by thoracentesis or tube
thoracostomy) and instillation of sclerosing agent to obliterate pleural space and
prevent fluid recurrence.
7. Administer oxygen by way of nasal cannula as prescribed.
8. Encourage energy conservation through decreasing activities.
9. Allow patient to sleep in a reclining chair or with head of bed elevated if severely
dyspneic.
10. Recognize the anxiety associated with dyspnea; teach relaxation techniques.
IMPROVING NUTRITIONAL STATUS

1. Emphasize that nutrition is an important part of the treatment of lung cancer.

a. Encourage small amounts of high-calorie and high-protein foods
frequently, rather than three daily meals.
b. Suggest eating major meal in the morning if rapidly becoming satiated and
feeling full are problems.
c. Ensure adequate protein intake milk, eggs, chicken, fowl, fish, cheese, and
oral nutritional supplements if patient cannot tolerate meats or other
protein sources.
2. Administer or encourage prescribed vitamin supplement to avoid deficiency states,
glossitis, and cheilosis.
3. Change consistency of diet to soft or liquid if patient has esophagitis from radiation
therapy.
4. Give enteral or total parenteral nutrition for malnourished patient who is unable or
unwilling to eat.

CONTROLLING PAIN

• Take a history of pain complaint; assess presence/absence of support system.

• Administer prescribed drug, usually starting with nonsteroidal anti-inflammatory
drugs (NSAIDs) and progressing to adjuvant analgesic and opioid agents.
o Administer regularly to maintain pain at tolerable level.
o Titrate to achieve pain control.
• Consider alternative methods, such as cognitive and behavioral training,
biofeedback, relaxation, to increase patient's sense of control.
• Evaluate problems of insomnia, depression, anxiety, and so forth that may be
contributing to patient's pain.
• Initiate bowel training program, because constipation is a adverse effect of some
analgesic/opioid agents.
• Facilitate referral to pain clinic/specialist if pain becomes refractory (unyielding)
to usual methods of control.

MINIMIZING ANXIETY

• Realize that shock, disbelief, denial, anger, and depression are all normal
reactions to the diagnosis of lung cancer.
• Try to have the patient express concerns; share these concerns with health
professionals.
• Encourage the patient to communicate feelings to significant people in his life.
• Expect some feelings of anxiety and depression to recur during illness.
• Encourage the patient to keep active and remain in the mainstream. Continue with
usual activities (work, recreation, sexual) as much as possible.
PATIENT EDUCATION AND HEALTH MAINTENANCE

1. Teach patient to use NSAID or other prescribed medication as necessary for pain
without being overly concerned about addiction.
2. Help the patient realize that not every ache and pain is caused by lung cancer; some
patients do not experience pain.
3. Tell the patient that radiation therapy may be used for pain control if tumor has
spread to bone.
4. Advise the patient to report new or persistent pain; it may be due to some other
cause such as arthritis.
5. Suggest talking to a social worker about financial assistance, or other services that
may be needed.

EVALUATION: EXPECTED OUTCOMES

1. Performs self-care without dyspnea

2. Eats small meals four to five times per day; weight stable
3. Reports pain decreased from level 6 to level 2 with medication
4. Verbalizes anger; practices relaxation techniques